Electrolyte Panel
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Electrolyte Panel | |
| 2. | |
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| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
LYTES
Test Workstation :
ACHM1
Specimen Type:
Blood
Tube Type:
Green top (lithium heparin) tube
Collection Volume:
1.5mL
Cause for Rejection:
Hemolysis or incorrect anticoagulant tube
Storage:
Refrigerated
Availability:
Daily, 24 hours; STAT
Methodology:
Ion selective electrode indirect
Special Instructions:
It is recommended that plasma be physically separated from contact with the cells within two hours from the time of collection.
Lab/Phone:
330-543-8417
TAT:
1 hour
Additional Info:
Reference ranges available under individual tests
CPT Code:
80051
Panel Includes:
Sodium, Potassium, Chloride, Carbon Dioxide
